RN VATI Maternal Newborn Remediation 2019 100% VERIFIED CORRECT NEW UPDATE, Study Guides, Projects, Research of Nursing

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RN VATI Maternal Newborn Remediation 2019

100% VERIFIED CORRECT NEW UPDATE

1. identification (using 2 identifiers) for the newborn is applied ANS - immediatelyafter birth by the nurse

• it is an important safety measure to prevent newborn from being given to the wrong parents, switched or abducted 2. how are the client, newborn & client's partner identified during the hospital stay? ANS identified by plastic ID wristbands with permanent locks that must be cut tobe removed

3. identification bands should include what? ANS the newborn's name, sex, date &time of birth & client's health record number

4. how many ID bands should the newborn have? ANS - one band placed on theankle and one on the wrist

• in addition, the newborn's footprints & client's thumb prints are taken

5. when should the ID band be checked? ANS each time the newborn is given to theparents, the ID band should be verified against the client's ID band
6. what must a facility member have in order to take the newborn? ANS - all facilitystaff who assist in caring for the newborn are required to wear photo ID badges

• the newborn is not given to anyone who does not have a photo ID badge that distinguishes that person as a staff member of the facility maternal-newborn unit

7. many facilities have locked maternal-newborn units that require ANS - staff topermit entrance or exit

• some facilities have a sensor device on the ID band or umbilical cord clamp that sounds an alarm if the newborn is removed from the facility

8. collecting blood samples for a newborn ANS - heel stick blood samples areobtained by the nurse, who dons clean gloves

• warm the newborn's heel first to increase circulation
• cleanse the area with an appropriate antiseptic & allow for drying
• a spring-activated lancet is used so that the skin incision is made quickly & painlessly
• follow the facility protocol for specimen collection, equipment to be used, and labeling of specimens
• apply pressure with gauze (do not use alcohol b/c it will cause bleeding to continue) until bleeding stops, and cover with an adhesive bandage
• cuddle and comfort the newborn when the procedure is completed to reassure the newborn and promote feelings of safety

9. where should a nurse perform a heel stick on a newborn's foot? ANS the outeraspect of the heel should be used, and the lancet should go no deeper than

mm to prevent necrotizing osteochondritis resulting from penetration of bone with the lancet

10. for sibling adaptation, the nurse should arrange ANS for one parent to spendtime with the sibling while the other parent is caring for the infant
11. for neonatal substance withdrawal, the nurse should consult ANS - lactationservices to evaluate whether breastfeeding is desired or contraindicated to avoidpassing narcotics in breast milk

• methadone is not contraindicated during breast feeding

12. physical assessment findings for endometritis ANS - uterine tenderness andenlargement

• dark, profuse lochia
• lochia that is either malodorous or purulent
• temp greater than 38 C (100.4 F)
• tachycardia

13. nursing actions for endometritis ANS - collect vaginal & blood cultures

• administer IV antibiotics
• administer analgesics

14. findings to report in third trimester ANS epigastric pain (gestational hyperten-sion)
15. lab tests for gestational hypertension ANS - liver enzymes

• blood creatinine, BUN, uric acid
• CBC
• clotting studies
• chemistry profile

16. nursing care for postpartum hemorrhage ANS - assess bladder for distention

• insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output

17. nursing care for uterine atony ANS - perform fundal massage if indicated

• if uterus becomes firm, continue assessing hemodynamic status
• if uterine atony persists, anticipate surgical intervention, s/a hysterectomy 18. expected findings for newborn infection, sepsis (sepsis neonatorum) ANS - color changes (pallor, jaundice, petechiae)

19. therapeutic uses of oxytocin ANS - induction of labor (postterm pregnancy, pre-mature ROM, preeclampsia)

• enhancement of labor (dysfunctional labor)
• delivery of placenta (postpartum, miscarriage)

• management of postpartum hemorrhage
• stress testing 20. at the end of the third stage of labor, the uterus should be palpable where? ANS at midline and 2 cm below the umbilicus

21. 1 hr after delivery, the fundus should be where? ANS should rise to the level ofthe umbilicus 22. every 24 hrs, the fundus should descend approximately how much? ANS 1 - 2cm
22. by the 6th postpartum day, the fundus should be where? ANS halfway betweenthe symphysis pubis & the umbilicus

24. where should the uterus lie after about 2 weeks postpartum? ANS within thetrue pelvis and should not be palpable

25. Rubella for postpartum mothers ANS - a client who is nonimmune to rubella orhas a negative or low titer is administered, a subQ injection of rubella vaccine orMMR vaccine during the postpartum period to protect a subsequent fetus from malformations

• the client should not get pregnant following the immunization

26. intraprocedure of labor process ANS - assess FHR to determine fetal well being

• this can be performed by use of EFM or spiral electrode that is applied to the fetal scalp
• prior to electrode placement, cervical dilation and ROM must occur

27. interventions for mastitis ANS use ice packs or warm packs on affected breastsfor discomfort
28. risk factors for gestational hypertension ANS - maternal age younger than 19 orolder than 40

• 1st pregnancy
• extreme obesity
• multifetal gestation

• chronic renal disease
• chronic HTN
• familiar hx of preeclampsia
• DM
• rheumatoid arthritis
• SLE (systemic lupus erythematosus)

29. anterior fontanel assessment on newborn ANS - should be palpable

• approx. 5 cm on average
• diamond shaped

30. posterior fontanel assessment on newborn ANS smaller and triangle- shaped
31. fontanels assessment on newborn ANS - should be soft & flat

• can bulge when the newborn cries, coughs or vomits, but should be flat when the newborn is quiet

32. bulging fontanels at rest on newborn can indicate ANS - increased ICP

• infection
• hemorrhage

33. depressed fontanels on newborn can indicate ANS dehydration
34. cutaneous stimulation strategies for pain management ANS sacral counter- pressure ANS consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back
35. nursing actions for reflex tachycardia ANS - monitor client's for an increased HR

• administer a beta blocker (metoprolol) to counteract tachycardia

36. terbutaline nursing actions ANS notify provider of HR greater than 130/min, chestpain, cardiac arrhythmias, MI, BP less than 90/60 mmHg, or pulmonary edema
37. intrauterine pressure catheter ANS - insert a sterile solid or fluid-filled IUPC insidethe uterus to measure intrauterine pressure

• displays uterine contraction patterns on monitor
• requires the membranes to be ruptured and the cervix to sufficiently dilated 38. oxygen therapy for respiratory depression following pain medication administration ANS provide oxygen therapy at lowest flow that will correct hypoxemia

39. respiratory depression nursing actions ANS - monitor VS

• stop opioids if client's RR is less than 12/min & notify provider
• have naloxone and resuscitation equipment available
• avoid use of opioids with CNS depressant medications (barbituates, benzos, consumption of alcohol)

40. causes/complications of late deceleration of FHR ANS - uteroplacental insuffi-ciency causing inadequate fetal oxygenation
    • maternal hypotension, placenta previa, abruptio placentae, uterine hyperstimula-

tion w/ oxytocin

• preeclampsia

• late or post-term pregnancy
• maternal DM

41. nursing actions for newborn hypoglycemia ANS monitor for jitteriness, twitch-ing, a weak or abnormal cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures & a blood glucose level less than 40 mg/dL via heel stick
42. physical assessment findings for newborn hypoglycemia ANS - poor feeding

• jitteriness/tremors
• hypothermia
• weak cry
• lethargy
• flaccid muscle tone
• seizures/coma
• irregular respirations
• cyanosis
• apnea

43. nursing care for meconium-stained amniotic fluid ANS suction mouth and noseusing bulb syringe if respiratory efforts are strong, muscle tone good, and

HR greater than 100/min

44. interventions for stabilization and resuscitation of airway ANS - the newborn isable to clear most secretions in air passages by the cough reflex

• routine suctioning of the mouth, then the nasal passages with a bulb syringe is done to remove excess mucus in the respiratory tract 45. nursing action for offsetting maternal hypotension after administration of an epidural block ANS administer a bolus of IV fluids

46. a major nursing priority for maternal-newborn clients ANS - prevention of falls

• nurses must evaluate all clients in health care facilities for risk factors for falls and implement preventative measures accordingly

47. danger signs during 1st trimester ANS abdominal cramping and/or vaginalbleeding (miscarriage, ectopic pregnancy) 48. nursing assessment for behaviors that facilitate and indicate parent-in- fant bonding ANS - provides physical care for the infant (feeding, diapering)

• responds to the infant's cries

49. normal temperature for a newborn ANS - 36.5-37.5 degrees C (97.7-99.5 F) with37 C (98.6 F) being the average

• the newborn is at risk for hypothermia & hyperthermia until thermoregulation stabilizes

• if newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur 50. nursing interventions to prevent variable decelerations of FHR during nonstress test ANS - reposition client from side to side or knees into chest
• discontinue oxytocin if being infused
• administer oxygen by mask at 8 - 10 L/min via nonrebreather
• perform or assist with a vaginal exam
• assist with an amnioinfusion if prescribed

51. nursing interventions for intraprocedure amniocentesis ANS - obtain & docu-ment baseline VS & FHR prior to procedure

• assist client into supine position, and place a wedge under their R hip to displace the uterus off the vena cava & place a drape over the client exposing only the abdomen
• prepare client for an ultrasound to locate the placenta
• cleanse client's abdomen with an antiseptic solution prior to administration of a local anesthetic by the provider

52. client education during intraprocedure amniocentesis ANS - understand therewill be a feeling of slight pressure as the needle is inserted
    • continue breathing, b/c holding breath will lower the diaphragm against the uterus

and shift the intrauterine contents

53. newborn (metabolic) genetic screening is ANS - mandated in all states

• a capillary heel stick should be done 24 hrs following birth
• for results to be accurate, the newborn must have received formula or breast milk for at least 24 hrs
• if the newborn is discharged before 24 hrs of age, the test should be repeated in 1 - 2 weeks

54. all states require testing for what in newborns? ANS - phenylketonuria (PKU)

• PKU is a defect in protein metabolism in which the accumulation of the amino acid phenylalanine can result in mental retardation
• treatment in the first 2 months of life can prevent mental retardation 55. what should nurse do immediately following rupture of membranes? ANS as- sess the FHR for abrupt decelerations, which are indicative of fetal distress to ruleout umbilical cord prolapse

56. what to monitor for in hypoglycemic newborns ANS - jitteriness

• twitching
• a weak, abnormal cry
• irregular respiratory effort

• cyanosis
• lethargy
• eye rolling
• seizures
• blood glucose level less than 40 mg/dL by heel stick

57. new ballard score (neuromuscular maturity) for newborn ANS - posture rangingfrom fully extended to fully flexed (0-4)

• square window formation with the neonate's wrist (- 1 - 4)
• arm recoil, where the neonate's arm is passively extended and spontaneously returns to flexion (0-4)
• popliteal angle, which is the degree of the angle to which the newborn's knees can extend (- 1 - 5)
• scarf sign, which is crossing the neonate's arm over the chest (- 1 - 4)
• heel to ear, which is how far the neonate's heels reach to their ears (- 1 - 4)

58. contraindications for oxytocin administration ANS - fetal factors

immature lungs cephalopelvic disproportion fetal malpresentation prolapsed umbilical cord

fetal distress placental abnormalities threatened spontaneous abortion

59. client preparation for induction of labor ANS initiate oxytocin no sooner than 4hrs after the administration of misoprostol, and 6-12 hrs after dinoprostone gel instillation or removal of a dinoprostone insert
60. excessive weight gain during pregnancy can lead to ANS - macrosomia andlabor complications

• inability to gain weight could result in low birth weight of the newborn

61. physiologic jaundice ANS - considered benign(resulting from normal newborn physiology of increased bilirubin production d/t the shortened lifespan and break-down of fetal RBCs and liver immaturity)

• the newborn who has physiologic jaundice exhibits an increase in unconjugated bilirubin levels 72-120 hrs after birth, with a rapid decline to 3 mg/dL 5-10 days after birth

62. nursing care for phototherapy for hyperbilirubinemia ANS - keep the newbornundressed

• for a male newborn, a surgical mask should be placed (like a bikini) over the

genitalia to prevent possible testicular damage from heat & light waves. Be sure to remove the metal strip from the mask to prevent burning

63. all states have a reportable diseases list ANS - HIV/AIDs is a commonly report-ed condition

• it is the responsibility of the provider to report cases of these diseases to their local health department